Capturing the patient's own words

Some contacts depend on the exact words used. Red-flag symptoms, safe-contact instructions, complaints, safeguarding disclosures and urgent distress can change the response needed if they are shortened too much.

When exact words matter

Exact words are important where the patient's phrasing affects safety, urgency, confidentiality or next steps. This includes descriptions of harm, fear, unsafe contact, worsening symptoms, medicine problems, self-harm, chest pain, breathlessness, collapse, reduced fetal movements, abuse, a complaint or a refusal of advice.

Use quotation marks for short, key phrases. You do not need to produce a transcript, but preserve words that would alter assessment or action.

Examples of useful detail

• Instead of: "breathing issue" - write: "patient said 'I cannot finish a sentence'".
• Instead of: "safe contact requested" - write: "patient said partner checks phone; requested no texts".
• Instead of: "complaint" - write: "patient said receptionist 'laughed at me' on Monday".
• Instead of: "upset" - write: "patient tearful and said 'I cannot keep going today'".

Keep notes proportionate

Record details that support safe action and continuity, but avoid unnecessary gossip, irrelevant personal detail and long emotional commentary.

If the wording changed the level of concern, the wording should usually appear in the note.

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